1. health and fitness
2. addiction
3. smoking addiction

PROJECT
NEWS
Generating knowledge for public health
M a rc h 2015
Responding to a Growing Need for E-Cigarette
Research in Ontario
e-cigarette knowledge gaps, and
guide future provincial policy
and legislation. This newsletter
highlights initial findings from
our knowledge synthesis, a study
of the effects of e-cigarettes on
cue-induced craving, analysis of
national survey data and a report
of findings from a longitudinal
panel of smokers.
The following components of the
RECIG study are well under way:
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Welcome to the second in our
series of four newsletters from
OTRU’s Research on E-Cigarettes
(RECIG) Project! We are happy
to be sharing information about
our activities and progress. Our
first newsletter discussed the
growing popularity of e-cigarette
use in Ontario and the urgency
of research to inform current
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Comprehensive knowledge
synthesis of e-cigarette
literature
Analysis of data from
existing e-cigarette surveys
Longitudinal survey to
measure patterns of
e-cigarette use among
adults (19 years and over)
Surveys and in-depth
interviews to understand
prevalence, attitudes and
knowledge of e-cigarette
use among youth and young
adults (15 to 29 years of age)
Social media analysis
of e-cigarette message
exposure, reach and content
In This Issue:
page one: Introduction
page two: Effectiveness of E-Cigarettes as a Smoking Cessation Aid, Effect on CueInduced Craving
page three: Prevalence of E-Cigarette Ever Use, Monitoring Trends of E-Cigarette Use
page four: AHRQ Invitation; References; Contact Information
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Randomized clinical trial
comparing smoking cessation
effectiveness of e-cigarettes
and nicotine replacement
therapy products
Biomarker study of
e-cigarette users to measure
concentrations of nicotine
and other chemicals
International,
multidisciplinary Expert
Panel to assess project
findings and identify
implications for public
health policy
Additional background
information on the RECIG project
can be found online in the OTRU
Update: Research on the Use and
Impact of Electronic Cigarettes
(http://otru.org/otru-research-useimpact-electronic-cigarettes/) and
the first Project News publication:
Introduction to RECIG: Research
on E-Cigarettes (http://otru.org/
introduction-recig-research-ecigarettes/).
PR
Effectiveness of E-Cigarettes as a Smoking
Cessation Aid
weak as indicated by a GRADE assessment of low to
moderate.
Preliminary Knowledge Synthesis Finds Evidence
for the Effectiveness of E-Cigarettes as a Smoking
Cessation Aid is Weak
Effect on Cue-Induced Craving
Great progress has been made since we provided an
update in the first RECIG newsletter on our knowledge
synthesis examining the prevalence of e-cigarette use,
health effects of e-cigarette use, the effectiveness of
e-cigarettes as a cessation aid, and the relationship
between the use of e-cigarettes and uptake of
cigarette smoking. Here we present preliminary results
of our analysis of peer-reviewed and grey literature
investigating the effectiveness of e-cigarettes as a
smoking cessation aid.
We identified and assessed 49 articles that investigate
primary and/or secondary outcomes related to the
effectiveness of e-cigarettes as a smoking cessation aid.
Primary outcomes measured:
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Smoking abstinence
Smoking reduction
Secondary outcomes measured:
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Withdrawal symptoms
Cravings
Nicotine delivery
The internationally-recognized Grading of
Recommendations Assessment, Development and
Evaluation (GRADE) approach was used to assess the
overall quality of evidence per outcome measure.1
Of the included studies, 23 were graded as weak, 23
were ranked as moderate, and only three had a strong
quality assessment.
The state of the evidence about the effectiveness
of e-cigarettes as a smoking cessation aid is
currently assessed as very low to low, due primarily
to methodological weaknesses of current studies.
Evidence of a positive association between e-cigarette
use and smoking reduction is slightly better but also
Electronic Cigarettes Demonstrate Some Effect on
Cue-Induced Craving in Daily Dependent Smokers
Craving is a crucial component of continued smoking
and relapse.2 Cue-induced craving involves urges
to smoke in response to environmental cues while
withdrawal-induced craving involves drug-seeking
to avoid negative effects when substances are
withheld.3,4 E-cigarettes can mimic conventional
cigarettes in taste and taction. Studies to date report
equivocal findings with respect to the effectiveness
of e-cigarettes to decrease craving and suppress
withdrawal symptoms, as well as their utility as a
cessation aid.5-7 The RECIG team is conducting a
randomized control trial to evaluate the efficacy of
e-cigarettes in reducing cue- and withdrawal-induced
craving in daily dependent smokers.
We plan to have 40 participants complete the study.
Currently, we have collected data for 32 daily smokers
(≥10 cigarettes/day; CPD) ages 18 to 65 with a
Fagerström Test of Nicotine Dependence8 (FTND) score
of 3 or higher, who have never smoked an e-cigarette
prior to the study and do not wish to reduce or quit
smoking.
Participants are randomized to one of four groups, each
receiving all the experimental conditions in a different
order. Conditions are: 1. tobacco cigarette,
2. e-cigarette with placebo lozenge, 3. e-cigarette with
nicotine lozenge, and 4. lozenge alone. Participants
are asked to abstain from smoking for 12 hours prior to
study visits. Expired carbon monoxide (CO), measured
by a Bedfont piCO+ Smokerlyzer® is used to confirm
smoking abstinence (CO ≤ 10ppm) at the beginning of
each visit.
The participants to date are 35 years old on average;
56% are female. They are moderately to heavily
dependent on cigarettes, smoking on average 18
cigarettes per day with a score of 6 on the Fagerström
Test of Nicotine Dependence.
Our preliminary results indicate that only the
e-cigarette plus nicotine lozenge condition was able
to suppress cue-induced cigarette craving for up to
Page 2
Ontario Tobacco Research Unit
ROJECT
NEWS
3 hours. All other conditions were able to suppress
cue-induced cigarette craving for 1 hour after use but
not after 3 hours. These findings suggest that nonnicotine e-cigarettes can suppress craving similar
to traditional cigarettes. The addition of a nicotine
lozenge prolongs the craving reduction for up to 3
hours.
Prevalence of E-Cigarette Ever Use
National Survey Finds High Prevalence of
E-Cigarette Ever Use, Especially among Current
Smokers
The Canadian Tobacco, Alcohol and Drugs Survey
(CTADS) is a general population survey of tobacco,
alcohol and illicit drug use among Canadians aged 15
years and older, that is conducted every other year.9
According to 2013 CTADS data, 16% of Ontarians
aged 15 to 24 years (15% of youth 15 to 19 years;
18% of young adults 20 to 24 years) have ever tried
an e-cigarette. Rates of use are higher among young
people who smoke; 73% of current smokers (smoked in
the past 30 days) between 15 to 24 years have ever tried
vaping. Individuals in this age group who have never
smoked tobacco cigarettes also demonstrated interest
in e-cigarettes; 8% of never smokers reported having
vaped at least once in their lifetime, representing close
to 128,800 Ontarian youth and young adults.
In Ontario, more than half (57%) of current or former
smokers aged 15 years and over who had ever tried an
e-cigarette reported using it as a smoking cessation
aid in the past two years. The CTADS survey did not
measure the effectiveness of e-cigarettes as a cessation
aid.
Nicotine-containing e-cigarettes were last used
by 26% of ever users of e-cigarettes (representing
approximately 165,300 individuals). The majority (53%)
of ever users reported that the last e-cigarette they used
did not contain nicotine, while 21% were unsure.
At a national level, ever use of an e-cigarette among
individuals 15 years and over (9%) is significantly higher
than rates in Ontario alone (6%). Close to 2% of the
Canadian population in this age group, representing
approximately 521,000 individuals, reported having
vaped in the last 30 days, indicative of current
e-cigarette use.
These CTADS findings are among the first to provide
a national snapshot of e-cigarette use in Canada and
demonstrate the need for longitudinal research to
identify vaping trends.
Monitoring Trends of E-Cigarette Use via a
Longitudinal Panel
Few surveys have measured the patterns of e-cigarette
use over time, largely because they are cross-sectional
in nature and take place over a short time frame. As
a result, these studies are limited in the guidance
they can offer policy-makers on the effectiveness of
e-cigarettes as smoking cessation tools or their ability
to act as a gateway to tobacco and other substance
use. In January, we launched a 6-month Adult Smoker
Longitudinal Panel to measure patterns of e-cigarette
use among adult smokers in Ontario.
Survey participants were recruited from three partner
studies: OTRU’s Smokers Panel, CAMH’s Smoking
Treatment for Ontario Patients (STOP) project, and
the CAMH Monitor. These participants previously
consented to be contacted for future research.
Participants were invited by telephone or email to
complete a web-based baseline survey and a six month
follow-up survey.
To be eligible for the Adult Longitudinal Panel,
participants were required to meet the following
eligibility criteria:
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18 years or older
Resident of Ontario
Ever-user of tobacco cigarettes (ever-users are
defined as having taken at least one cigarette
puff in their lifetime)
A total of 1,962 participants were included in the
preliminary analysis. Highlights from the Adult
Ontario Tobacco Research Unit Page 3
Generating knowledge for public health
Longitudinal Panel baseline survey:
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64% (n = 1254) of participants have ever used an
e-cigarette
35% (n=436) of ever users have used an
e-cigarette in the last 30 days
80% of ever users reported first using e-cigarettes
as a way to reduce or quit their tobacco use
(n=998); among these participants (n=998),
18% (n=183) reported having successfully quit
smoking tobacco cigarettes with the help of
e-cigarettes, and 78% (n=781) reported being
somewhat or very successful at cutting down
their tobacco use while using e-cigarettes
54% (n = 673) of e-cigarette ever users said the
last e-cigarette they used contained nicotine;
29% (n=368) said their last e-cigarette did not
contain nicotine and 17% (n=213) did not know
Invitation to Propose Additional Research
Questions
This grant provides the opportunity for Applied Health
Research Questions (AHRQ). An AHRQ is a question
posed by a health system policy maker or provider
(Knowledge User) in the interest of obtaining research
evidence to inform planning, policy, and/or program
development that will benefit the broader Ontario
health system. Knowledge Users are invited to submit
a Knowledge Request to Research Providers with the
goal of identifying research gaps and opportunities for
knowledge generation.
For more information about initiating an AHRQ request,
contact: Robert.Schwartz@utoronto.ca
416-978-3901
References
1. Kunz R, Burnand B, Schunemann HJ. The GRADE System.
An international approach to standardize the graduation
of evidence and recommendations in guidelines. Internist
2008;49(6):673–680.
2. Tiffany ST, Warthen MW, Goedeker KC. The functional
significance of craving in nicotine dependence. Nebraska
Symposium on Motivation 2009;55:171-197.
3. Ferguson SG, Shiffman SJ. The relevance and treatment
of cue-induced cravings in tobacco dependence. Journal of
Substance Abuse Treatment 2009;36:235-243.
4. Shadel WG et al. Lapse-induced surges in craving influence
relapse in adult smokers: An experimental investigation.
Health Psychology 2011;30:588-596.
PROJECT NEWS
5. Etter JF, Bullen C. Electronic cigarette: Users profile,
utilization, satisfaction and perceived efficacy. Addiction
2011;106:2017-2028.
6. Vansickel AR et al. A clinical laboratory model for
evaluating the acute effects of electronic “cigarettes”:
nicotine delivery profile and cardiovascular and subjective
effects. Cancer Epidemiology, Biomarkers & Prevention
2010;19:1945-1953.
7. Bullen C et al. Electronic cigarettes for smoking cessation:
A randomised controlled trial. The Lancet 2013;382:16291637.
8. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO.
The Fagerström Test for Nicotine Dependence: a revision of
the Fagerström Tolerance Questionnaire. British Journal of
Addiction 1991;86(9):1119-1127.
9. Government of Canada. Canadian Tobacco, Alcohol and
Drugs Survey: Summary of results for 2013.
RECIG Research Team
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Jaklyn Andrews, Research Officer
Muhannad Malas, Research Officer
Aliya Noormohamed, Research Coordinator
Jan van der Tempel, Research Officer
Contact Information
Dr. Robert Schwartz
Ontario Tobacco Research Unit
c/o Dalla Lana School of Public Health
University of Toronto
155 College Street, Unit 536
Toronto, ON
M5T 3M7
Robert.Schwartz@utoronto.ca
The Ontario Tobacco Research Unit (OTRU) is an
Ontario-based research network that is recognized
as a Canadian leader in tobacco control research,
monitoring and evaluation, teaching and training and
as a respected source of science based information on
tobacco control.
The views expressed in this newsletter are the views of
the Ontario Tobacco Research Unit and do not necessarily
reflect those of the Province of Ontario.
Paid for by the Government of Ontario
Page 4 Ontario Tobacco Research Unit